Understanding 340B and Contract Pharmacy - Iowa … 340B and... ·  · 2015-01-13Understanding 340B and Contract Pharmacy Julie Houston, B.S., Ph.T Director, 340B Retail Solutions

Understanding 340B and

Contract Pharmacy

Julie Houston, B.S., Ph.T

Director, 340B Retail Solutions

McKesson

– 340B 101

– 340B Regulatory Update

– Contract Pharmacy Basics – How It Works

– Role of 340B Vendors

– Business Opportunity/Vendor Models

– Business and Program Considerations

– Questions

Topics for Discussion

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340B 101

What is the 340B Program?

• Federal program created in 1992

• Benefits providers serving the indigent

• Discounted pharmaceuticals

• Outpatient drugs only

• Compliance & administration

• Creates an opportunity for “covered

entities” to contract with retail pharmacies

to improve access

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340B Covered Entities (CE’s)

• FQHC and look-alikes

• Consolidated health centers

• Family planning

• HIV / ADAP

• Black lung

• Hemophilia

• Native Hawaiian

• Urban Indian

• STD

• TB

• DSH

• Critical access hospitals

• Sole community hospitals

• Rural referral centers

• Freestanding cancer centers

• Children’s hospitals

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Increased scrutiny by Congress – Focus on program oversight and integrity provisions

– Disagreements surrounding intent of program (patient subsidy vs. covered entity subsidy)

– Focus on use of program savings or “revenue” – profiteering?

– Impact on drug shortages

– Pointed letters to hospitals and Walgreens

PhRMA, PBMs, and Oncologists have raised concerns about program scale and patient benefit

– AIR 340B

– Negative editorials in national publications

– White Paper, “Unfulfilled Expectations…”

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Current 340B Challenges

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340B “Mega-Reg”

– Eligible Patient Definition

– Contract Pharmacy

– Hospital Eligibility

– Off-site Facility Eligibility

– Date of rule publication and impact in question due to…

PhRMA vs. US DHHS

– May 2014 ruling by US District Court in favor of PhRMA

– Ruling states that HRSA does not have authority to create the orphan drug regulation published in Fall 2013

– Impact on Mega-Reg

– Impact on previous program guidance?

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340B Policy Focus

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Contract

Pharmacy

Where did this all come from?

• Federal Register, Volume 75, No. 43 – Friday, March

5, 2010 Notice

– Multiple contract pharmacies allowed

– Contract requirement, suggested provisions

– Essential compliance elements

– Compliance expectations

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Contract Pharmacy: How Does It Work?

The Prescription Process

Third-Party

Software

Vendor

Clinic / Hospital Payment,

Retain Vendor Fee

Rx Claim

Pharmacy Processes

and Dispenses 340B

Prescription

Hospital / Clinic Replenishes

Retail 340B Stock

Reimbursement

$80

$60

$15

$5 $20

$85

$100

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340B Software — What Does It Do?

• “Captures” eligible 340B prescriptions by

comparing the pharmacy’s Rx records with a file of

covered entity patients and prescribers

• Tallies the cost and reimbursement for the

“shared” 340B Rx’s

• Maintains a “bucket” of replacement drugs for the

covered entity to purchase

and ship to the contract pharmacy

• Provides reports of reimbursement, dispensing

fees, 340B savings

and financial settlement

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Business

Opportunity

Financial Screening Model

• Prescriptions are screened for revenue to hospital

• Screening impact varies for retail pharmacy

• Can be difficult to forecast retail pharmacy results

• Program leans on brands and high cost generics

• 340B conversion rate can be low (<20%)

• Admin fees $4 - $6/Rx

• Dispensing fees $15 - $25 /Rx

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All Prescriptions Model

• All prescriptions are converted to 340B

• Hospital and pharmacy have winners / losers

• Financial results can be forecast for retail pharmacy

• Program can impact retailer’s generic contracts and rebates

• Extracts maximum savings from 340B program

• Admin fees rely on pharmacy 340B fill rate

• Dispensing fees $15+

• Admin fees $0.15 - $0.45 / Rx screened for 340B

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Gain Share Model

• Screening methodology similar to “financial screening model”

• Admin fee 15% - 20% gross prescription revenue

• Some covered entity pushback owing to % admin fee

• Beltway discussions regarding % admin fees and Anti-Kickback statute

• Dispensing fee $15

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“Do it Yourself” Model

Participants can and do support 340B without the use of a 340B Vendor

However, there are multiple factors to consider, including:

• Development of contract

• Identification of eligible scripts

• Tracking and reporting inventory use

• Financial reconciliation/identification of 340B claims from consolidated 3rd

party payment

• Compliance records and reporting in the event of an audit

• Current pharmacy resources and contribution

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Business

Considerations

The tipping point towards accountable care is driving needs – and opportunity - in new areas

Pharmacy well positioned to take a role

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Key Considerations

Compliance / Politics

• HRSA / Manufacturer audits

• Congressional scrutiny

• Medicaid billing and rebates

• Federal Anti-Kickback statute

Reimbursement

• Reduced reimbursement contracts

from PBMs

• Medicaid

Business Operations

• Inventory swell

• True-up

• Management / Finance time

• Purchase agreements

• Wholesaler totes

Competition

• Software vendor responsibility

• Large chain networks

• Clinic / hospital pharmacies

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Questions?